We received the case study that follows over the transom via email from a reader I’ll call Mr. B for Belgium; Mr. B’s story vividly illustrates the exceptionally bad nature of the United States health care system when compared to other industrialized — indeed, civilized — nations like Belgium. But then I got to thinking: I can’t remember any investigative journalism on ObamaCare that aggregates the experiences of those who are less than satisfied with it. So I thought I’d remedy that lack, after letting Mr. B speak and giving some detail on the Belgian system.

Most of the material that follows focuses on the “individual market,” that is on the ObamaCare exchange. But I’m very interested in stories about other health care systems, like Medicaid, Medicare (in all its various Parts), as well as the Veterans Administration and even the Indian Health Service. So please feel free to add to our trove of anecdote in comments!

Case Study: Belgium vs. The United States

Mr B speaks:

This is not a link, but an anecdote on healthcare. I have appreciated your coverage on Obamacare over the years and wanted to add a bit of personal experience just to let you know that I think you are on the right track and in predicting and covering the ‘crapification’ of healthcare, and I hope you keep it up.

I am an independent consultant, buying on the exchange in the state of Virginia. Because I used to spend much time outside of the country–and Obamacare does not offer good options for people who are outside of the country–I originally had the cheapest healthcare option. Note that while I was spending about 7 months outside of the US, I still had to buy from the exchange because the cutoff for being eligible not to be fined is 9 months outside of the country.

The first year that I bought insurance, I tore my meniscus in Paris and had to have surgery in Belgium. At the time, I considered coming back to the United States for surgery so that it would be covered. I decided against it because–due to the size of my deductible–it was actually much cheaper for me to pay out of pocket for surgery in Belgium than to come back to the United States where I was covered.

Frustrated by this experience, the next year (2015) I bought the a Platinum plan on the exchange–higher premium, higher monthly payments, low coinsurance, lower copay, and most significantly, a much lower out-of-pocket maximum of $US 1500. If I had had this year before, I would have made sense for me to have surgery in the United States.

At the end of this year, I received a letter saying that this plan would no longer be available, but I would be switched to a new plan that cost $US 30 more a month, had higher co-insurance, my deductibles all went up by about $US 1000 dollars, and my out of pocket maximum went from $US 1500 to $US 6,850. Of course, I was able to go on the exchange and look for other plans, which I did. But it turned out this was the best plan in that category offered for that year, but by and larger there was not a great disparity between the plans offered by…roughly three insurance companies on the Virginia exchange. In short, no real competition.

It the beginning of March, my plan has been in effect for less than 2 months, and, in that time, I have received notifications that my one prescription drug–a nasal inhaler–will not be covered. Mind you, due to my deductible, I was already paying $US 240 dollars for the prescription. Last week I received a notice from my orthopedist saying that are being forced out of the network because they this year UnitedHealth Group, my provider, is demanding that they cut their fees by half.

To be clear–maybe my orthopedist is overcharging. I cannot know this because the medical costs in the United States are not transparent. In truth, looking at my bills, some of these costs do seem high. That said, here is a link to UnitedHealth Group’s executive compensation, from which you can see that the CEO earned $65 million USD from the period through 2010 to 2014, and that the year-on-year change in total executive compensation between 2013 and 2014 was +36.3%. Whether the blame lies mostly with the insurance company or the provider, or somewhere in between what you have is a clear picture of people getting screwed while private companies fight over the spoils–and at least in the case of UnitedHealthcare, do quite well while their clients do worse and worse.

As a final point, I called UnitedHealtcare to complain and received fairly indifferent treatment. This is not surprising because:

1. I have to buy insurance or I will be fined

2. They are probably well aware that their competitors are offering the same awful plans that they are

3. While they are not locked into the insurance they give me–they are free to continue to take away my coverage by pushing providers out of the networking through the year–I cannot change my insurance company until the end of the year.

Thus while we have a privatized insurance system in that people at the tops of companies are allowed to collect grotesque profits, it is in no way a free market system because the people who are compelled into it have no real choice.

Anyway, thank you for taking the time to read this. I hope that the information can be of some use to your bloggers, or simply serve as reinforcement that you are quite on the right track in your instincts on health care. Thank you for all of your coverage and work.

There just isn’t any level on which Mr. B’s experience isn’t ridiculous. I’m sure many of you could share similar experiences, no matter which of our many heatlh care systems you are enmeshed in. Since Mr. B actually had his surgery done in Belgium, a word on their system. Xpats describes it; note it’s not a pure single payer system, but a hybrid system with a mandate.

To benefit from the healthcare system in Belgium, you have to join a health insurance fund. The majority of these funds are linked to the country’s political parties [!!] but they are accessible to everyone. You can choose from 20 Christian, 13 socialist, 10 liberal, seven independent and seven neutral funds from all over Belgium. Contributions are withheld from your income if you are a salaried worker; the self-employed need to register with the social security fund of their choice. All funds charge the same amount, as they act as intermediaries between the National Institute for Sickness and Invalidity Insurance and its members. This state system provides basic healthcare reimbursements for hospital, doctor and chemist costs – for example, 50-75% of the cost of a consultation with a doctor or specialist

You can opt for an additional insurance. This covers repayments for non-urgent care in hospital, the costs of glasses, dental care, vaccinations and registration at a sports club. Alternative or complementary treatments such as homoeopathy, acupuncture, osteopathy and chiropractic are also recognised as reimbursable by the Belgian Ministry of Health, if the practitioner is a qualified doctor. The content and cost of this insurance varies for each fund. However, it is possible to choose complementary insurance from one of the private companies which come under the umbrella organisation Assuralia.

As a physician, I enjoyed the “simplicity and efficiency” of the system. My patients and I enjoyed the “freedom from pecuniary concerns.” Payments for my services were prompt, never questioned, never lowered and never denied. I never called the insurance system for permission to provide care and they never called me; they never asked for and I never sent them a report of any kind. I never had a secretary or a receptionist. With part-time help from my wife, I managed a busy practice well enough without managed care.

The Belgian health system has been in place, basically unchanged, for 40 years. In 2000, it spent $2,269 per inhabitant and 8.7 percent of the gross national product, compared with $4,631 and 13 percent in the United States. My friends and colleagues in Belgium assure me that health care they receive or provide is excellent and dependable.

No wonder Mr. B’s surgery went so well. Of course, Americans must never ask for a health care system like that. That wouldn’t be pragmatic.

Aggregated Reader Comments on ObamaCare and the Health Care System

I’ll now turn to the steaming load of crap Americans have instead of a civlized, human sytem like Belgium’s. Needless to say, this being the Naked Capitalism commentariat, the stories are detailed and credible. Of course, these comments are self-selected, since most NC posts on ObamaCare are critical, so what follows is in no sense objective. But every time I post on ObamaCare, I get at least one horror story, generally a lengthy one. If ObamaCare were anything like buying a flat-screen TV, in Obama’s famous phrase, that just shouldn’t be happening.

I collected these anecdotes from the comment sections of the last ten posts on ObamaCare; the latest comments are at the top, and edited them lightly. I can’t really think of an organizing principle for the horror stories that follow, which seems right, given the givens; it’s like we need a TV Tropes for bad government systems. So I’ll pull out keywords from the text, and put them in subheads, following the commenter’s handle. And again, readers, please add your own stories in comments.

So this is a topic I can speak about with first hand knowledge. I have been in the so called “individual insurance market’ since 2009. When I first bought insurance for our family of two adults and one child in 2009 our premiums were $410 per month with a $5k deductible. The insurer was Anthem and the coverage and benefits were excellent and the network was extensive. The premiums increased steadily each year and by 2013 we were paying about $600 per month in premiums for the same plan. That was a pretty healthy increase in premiums over 5 years but nothing compared to what happened when the ACA kicked in. At the end of 2013 we received notice that our old plan was being terminated and offered a new plan at the cost of $1,675 per month with a $5k deductible. Needless to say I was stupefied to see our premiums nearly tripled!!! I called the Connecticut State Insurance Commissioner’s office to ask how this was possible and was told that rates had indeed gone up dramatically in the state as a result of the ACA and it had absolutely noting to do with enhanced benefits since CT had long mandated comprehensive coverage for all plans sold in the state. Rather, our rates increased astronomically because we were no longer “under written” meaning our policy was no longer priced according to our age, health, etc. The insurance commissioner’s office explained that rates were so much higher because of the expected cost of insuring people with pre-existing conditions and that the state had thereby authorized dramatic rate increases.

One can argue that this is good public policy but form our perspective it destroyed the individual insurance market and took $13k in after tax dollars directly out of our pockets. The story gets even worse. Prior to the ACA all of the expenses associated with my annual physical exam were covered but under the ACA I have had to pay about 35% of the total bill because a couple of the routine screening tests that were covered under the old plan aren’t covered any longer.

In addition shopping for insurance has become a complicated nightmare with scores plans with endless permutations that are nearly impossible to decipher. And that is before you even begin to try and understand the network issues which are a nightmare.

The ACA is a sick joke as far as I am concerned. As for all the poor people who can now supposedly afford insurance, well that is a load of BS propaganda. There is no way most families can afford these plans even if they get a “subsidy”. And with $5k deductible most people avoid going to the doctor under these plans.

So the issues you discuss are a reflection of this warped and predatory system that has been forced on us. The worst part of all this for me personally is that I supported heath care reform for multiple reasons but I should have known that once the world’s most disreputable and skanky whorehouse got involved nothing good was going to happen.

From 2008 to 2009 my single person costly coverage went from about 700 a month to over 1,000,

I called the insurance company- “name one single cost that has gone up in 2008, just one”….nothing.

State AG was in no luck, they are federally exempt from anti-trust statues. I even called the state police to ask what would be required for them to be charged with extortion. We ended up agreeing that, by the letter, and intent of the law, they were guilty, but they couldn’t do anything without the AG.

Then this cherry on top, after my original very expensive 700 went to over 1500, and I said fuck it-

http://www.rbj.net/print_article.asp?aID=207198

Ex-CEO Klein to collect some $29.8M

Originally reported at ONLY 12.9 million.

His picture should be in every dictionary under “non-profiteer”. BCBS is non-profit, remember. For whom, they never say….

[This has been] experience I’ve had with my mother’s insurance travails on the individual “market over the past decade +. Increasing premiums, increasing deductibles, shrinking networks. All of these trends have picked up speed since Obamacare went into effect. It is a sick joke indeed.

That $6,000 deductible is at most a best-case scenario, too. What with small networks on most plans, this can quickly turn into many times that.

As for the craptacular website and bureaucracy of 0Care: “0bamacare is great! /sarc. It’s an enormous time drain. Just got an 0Care notice for my mother’s coverage. Apparently they STILL have a data verification issue concerning her citizenship and threaten subsidy recovery. Mind, I submitted the copies of the US passport and Naturalization Certificate BOTH electronically AND through the mail last December. How much more ridiculous can this BS get?! As I type this I have been on the phone with 0Care marketplace for 40 minutes and no one can get to the bottom if this, except to suggest that I mail copies, AGAIN. Thanks 0bama!”

That phone call ended up lasting a bit over an hour, and ended with the promise that the issue was being “escalated” and someone will call in the next 30 days. Holding my breath I’m not.

Just paid our monthly premiums for myself (64) and my mate (57). We have the cheapest policy available in our state (WA). It is $985/mo. w/of course, a $6k deductible…ea. So…we pay almost $12,000.00/ year for a policy that never covers anything until we are hit by a bus. Luckily for the insurance co. we live on an island w/o roads.

Since I work as a contractor, before Obamacare I was using Freelancer’s Union for my insurance and was paying around $600/month for a very solid plan with no deductible (in network). The network was robust and I had relatively few complaints. Now Freelancer’s Union doesn’t have a plan anymore, just directs us to the NY health exchange. I couldn’t find a plan that included any of our doctors for less than $1,000/month with a $4k deductible, and lord knows how rotten the narrow network really is. All of which means we haven’t been insured for years and don’t see any light at the end of Obama’s awful tunnel of garbage “insurance”. Sickening, and we’re supposed to vote for Hillary who is now apparently “for” (*TM) a “public option”. Why am I not excited? Of course we’re feeling the Bern. How can we not?

Together my husband and I curently pay $1,300. premiums monthly which reflects a BCBSAZ grandfathered plan that increased around 20% this year and his ACA premium plan that incresed 38%. Both with no significant claims $4,500. deductibles, $50. co-pays for office visits etc.

It’s incredible and mind boggling but we can’t risk being w/o insurance.

I can’t imagine the young or healthy, likely already burdoned with crushing student loans will suscribe to this and the majority living paycheck to can begin to afford it.

The sophistry of the system is preposterous. Imagine the Canadian health care system was created on 3 pages.

Why aren’t people rushing to sign up for Medicaid? As I have 15 years of experience dealing with the program in New York State, I can tell you the reasons are many.

If a Medicaid enrollee calls a hospital ‘referral line’ to get the name of a doctor, your are steered to a Medicaid clinic (although it is not required) because federal reimbursement rates for clinic visits are at least 20% higher than that for in-hospital doctor office visits.The waiting times in Medicaid clinics are appalling, an average of 1.5 to 3 hours past your appointment – so if you have the temerity to be poor but working, you would have to take the day off, which would jeapordize your income, and perhaps your job. The Medicaid clinics are, of course, training grounds for interns and resident doctors, who rotate through every 6-8 weeks. This means anyone with chronic conditions (CVD, diabetes, hypertension – classic diseases of poverty), never have the same doctor for any real length of time, with a gross lack of continuity of care – a breeding ground for medical errors and neglect

On top of all this, NY has joined 17 other states in the Obamacare ‘FIDA’ pilot. This crapification maneuver forces anyone with Medicaid, even if they have Medicare as their primary insurance, into HMOs or ‘managed care plans’. These naturally have narrow networks, few specialists in any particular catchment area, and those specialists are overbooked and of mediocre quality. God forbid you have a neurological condition, autoimmune disease, or other ‘exotic’ illness – specialists do not exist.

The only current exceptions to FIDA in NYS are Medicare/Medicaid patients who do not need homecare, or Medicaid enrollees in one of 2 ‘waiver’ programs (there used to 5). The Medicaid waiver programs cover either developmentally disabled children, or traumatic brain injury patients. I fled to the TBI waiver program to avoid FIDA, as it was supposed to provide more targeted services. However, I discovered that the TBI program was thoroughly corrupt – there was no state oversight of contractors; indeed, the state director of the program was aiding and abetting them. My local program provider was being paid about $4k/month to provide services to me, including 40 hrs/week homecare, but for 9 months I had no assistance whatsoever. After a 1 1/2 years of struggle (with help from 2 public interest attorneys, no less), the problems were still not repaired, so I had to return to FIDA.

Cuomo and Obama are hard at work turning Medicaid into a complete sump.

I know two people who are dropping their “exchange” coverage, because they were misled concerning subsidies. One has a decently-employed husband; she was told by a navigator that she was eligible for hefty subsidies. Then when her tax bill came due, it turned out she wasn’t, and she had a very big (I don’t know the exact number) tax bill because the family income was higher than predicted. They can afford to pay it, but she is very disgusted. Another is a close family friend who has a small business (she used to clean houses; now she does online sales) who didn’t have health insurance for years. She signed onto the exchanges and got a hefty subsidy. Then, her tax bill came due and voila, she owes $6,000 because her income was “higher than predicted.” She can in no way pay this (she is trying to work out a deal with the IRS) and also pay premiums; she is now dropping her insurance coverage and will be back to no insurance again.

I don’t have a big social set but if I know two people who had this happen to them I doubt it’s rare. I think that the “navigators” misled people about eligibility for subsidies to get them to sign on to boost enrollment numbers. Only when their tax bill arrives do they find out they are screwed. And it is very complicated; our family friend’s CPA can’t figure out exactly what is up.

Another personal story of clusterfuck in the ACA, Covered California style: Due to increasing penalties this year, finally signed up! Picked a plan and everything, and was even happily surprised that coverage areas and available plans had mightily improved this time around. Not that hard to get an affordable plan with doctors in our area, unlike previous years.

So we get an email telling us if we haven’t gotten a bill yet, check online. I double check the unopened mail, and in fact I have one thing from blue cross anthem or something like that telling us how to go online and see more info about our plan, and another thing from covered california that has our income estimate completely wrong telling us we need to hurry up and pick a plan or coverage will be delayed, but no bill. So I go online to check out my plan. Anthem or whoever it is says they have no record of us! Covered California has no record either, and does have our income estimate way too low, so low it would entitle us for medicaid. While saying our income is too high for medicaid and we have to choose something else, even tho we never tried to choose medicaid. We tried for hours to get something going and finally gave up. Eventually one of us will probably do something again to check on it. Probably. Would think this was the kind of typically weird thing that happens to us but in this case it seems to be happening to lots and lots of people and be closer to the norm than to weirdness. I dunno who set this up but competence is not their strong suit.

My experience is that there IS no “competition” in any product field that involves actuarial calculations. I get a subsidy and I am 63. There were about 50 plans offered in my area. A few were OVERpriced, yes, but the vast majority offered very similar premium prices, and identical elephantine deductibles, which means that except for aspects of the annual physical, it will “cover” ( assuming cover means pay for) jack. “Coverage” is not care, it is nothing to brag about. I am “covered” for expenses beyond my deductible as a form of catastrophic insurance but the plan will never pay for anything else and actuarially, it is easy to calculate a premium that guarantees that companies will make lotsa money while paying out less. Needless to say the “product” is outrageously overpriced for what it covers and puts people like me _- close to medicare but limited income and owns own house free and clear in a far far worse position than before the law. ( eg medicaid asset recovery if I dare to state a lower income etc etc). So I’m “covered” , so what. I have far less actual care. And that , it appears to me , is deliberate.

Even if it were “competitive” there is not much point in comparison shopping for flat screen tvs.. for a flat screen tv with X features made by brand “A” the price difference for a tv with the same features ( and longevitiy) of brand “B: will in the vast majority of online offerings, be so close as to not be worth the effort. This is even more true with insurance.

Like most politicians, Obama wanted to “do something” and a have a bill he could hold up in front of Everybody and say “see this is mine”. My experience with such legislators/administrators is that they have a lot of hubris and grees for the bill to pass and do not subject potential downsides to any critical analysis so that advisers get the message “construct something that will pass” .The fact that he was dumb enough not to see this coming suggests that his “ideology” was driven by his advisers- who are definitely neocons IMO not neoliberals unless the term “liberal” is used in its classic economic sense.

And while we are on the subject, “Health care” is not really subject to “market” principles. Start with the fact that most people in this country have less than 1K savings, which means that they cannot cover the ginormous deductibles most “silver” plans offer or the premiums of better plans. Then add in the fact that these people cannot predict how much care will be needed in a given year or what the final cost of that care will be. What’s the “market ” for that? Under these two facts mandatory “insurance”with high deductibles and narrow networks simply functions as a wealth transfer from strapped lower-middle and middle class adults to Insurance company shareholders and CEOs.

Even assuming that Obama “wanted” single payer- an assumption that has been ably refuted in this string already, had he given “what can get passed” a moment’s critical analysis, he might have realized that he- with his insistence on change for change’s sake- was making it worse for so many Americans. I for one , could care less that pre-existing conditions are now “covered” if I can’t actually use the coverage- pre existing survives, its now called high deducitlbes and narrow networks.

As Chromex notes, Obamacare “coverage” is high-deductible catastrophic, so all day-to-day “care” is paid for out of pocket. But just try finding out how much a procedure costs… I needed an MRI on my knee, and it took three phone calls to find out how much I would be paying for the procedure. First you need to know the exact billing code for the procedure, which means you need to find the person in the doctor’s office who is anointed in the mystical realm of billing codes; then you need to call the insurance company customer service rep, who is initially mystified that you are actually trying to find out how much something costs; then you (hopefully) transferred to someone in the billing department (who has never spoken to an actual patient before); and finally, if you are lucky, in two or three weeks you will revive a letter from another anointed person giving the actual out of pocket cost of the procedure—which will probably be different after the fact as “adjustments” are made between provider and insurer.

I will apologize in advance for the tone but I am angry. Potentially losing my son, our home and our entire retirement savings will do that to a person…

Our son has severe dyslexia and a sky high IQ. He also has chronic kidney issues for which he is hospitalized several times a year each and every year. It is taking him quite a few years to get through college because of these two situations and thus fell off our insurance at 26 though he is still in college doing a double major in microbiology and neuroscience. Through Obamacare he stayed on our excellent insurance an extra three years from 23 to 26 thank heavens.

Before ACA when he tried to get his own policy that would cover him fully for his kidney issues he was turned down by ALL companies for anything related to kidneys in any way. Even so far as excluding some slight extra specific kidney function testing done in bloodwork. It was nuts.

Just for your erudition last year’s total bills for kidney issues were $638, 854. Do you think a colleges student has that kind of money? Really? We would have had to cash in our retirement savings and sell our house to pay for a couple of years of that. So would most of the American middle class. We are fiscally responsible college educated people living in a fairly modest home albeit in suburban metro area considered on the slightly more pricey side ( not like NYC of LA or course).

Through the ACA he was able to get a good policy for himself( that we pay for of course as he is still in college this year finishing up) that covers his massive bills with an affordable deductable for us.

I dislike most of the people in both parties and think they are all shills for business interests and Obama has been a massive failure in my book for most things. But the ACA literally saved my son’s life AND saved us from being totally penniless in to retirement or destitute within a few years. Our house we bought in 2007 is still worth 200,000 +less than we paid for it despite my skilled husband having rebuilt the damn thing from top to bottom so in forced selling we would lose the paper equity we put down. I am still waiting for the rebound in real estate with bated breath…..

NC features pieces from themselves others constantly… which salivate over tearing down and wanting to sweep away the ACA. For all its blatant giveaways to the insurance/pharma oligarchs and other evils, scrapping it would literally kill/financially ruin us and my son. KILL. NOT ‘just hurt a little’. KILL. So THINK a little before you open your your damn snotty self righteous mouths. Real easy to be cavalier with other peoples’ literal survival. ‘Something’ is far better than the brutal ‘nothing’ we had for some of us real live middle class people out there……

I don’t know if I will even vote for a presidential selection or other national office this year because of the dearth of people who give a damn about the citizenry who are running. Sanders talks a good game but the piranhas in Washington will never allow him to make more than a window dressing change in the meager steps already taken to improve healthcare access.

Work instead please for changes to the ACA which will make a real positive difference in peoples’ lives and bring down the multinational healthcare cabal who runs the show. It is what I talk about when I show up to my US Representative’s office each month and to my two Senators staffers when I do the same to their regional offices. If every single person would do this like I do each every month we would have single payer health care with every single person inside this country fully cared for. I wouldn’t have to lay awake and worry each and every night about what if someone on their smug high horse gets rid of the ACA and we run out of money and then….. my son dies…

I hate to break some bad news to you — and this will vary according to where you live — but I have been eligible for Medicare for several years, and it is EXTREMELY difficult to find a doctor who takes Medicare patients.

My original doctor, whom I’d used for many years, first (seven years ago) stopped taking NEW patients who were on Medicare, and shortly thereafter kicked out any of us ON Medicare — even those of us who’d been with her long term. Oh, I could “stay” with her, but I’d get to pay for my own costs, unless, of course, I could get a “new” insurance policy at 65+. Insert maniacal laugh here.

Where I live — the metropolitan DC area — eliminating Medicare patients is no financial threat to doctors, since there are so many federal and contractor employees with excellent coverage to replace us.

When this problem arose for me, I talked to several friends in similar situations, and they too could not find a doctor to accept them as a patient. Again, this was for folks covered by MediCARE, not the dreaded MediCAID.

my anecdote, I’m somewhere under 30, healthy, mindful of my health and have no family health history of anything extraordinary.

Between the premiums and deductibles/coinsurance/copays of the available plans, literally the ONLY way Obamacare would make sense for me is if I got hit by a drunk driver on my next outing to the grocery store. Or I find some tumor lump.

Now obviously those bad odds aren’t zero……but I’m willing to take on that actuarial risk in order to have some extra cash to pay my student loan debt and make ends meet.

Besides given my financial circumstances, if I got hit by a drunk driver and admitted to an ER, the deductible by itself would ruin my finances/set off a cascade of defaults as I don’t have any sort of short-term/long-term disability insurance/workers’ comp, etc.

Recently helping a just-turned-26 child shop on a state exchange drove home the insanity of the ACA, which until now had been an abstraction. Unless you have years of experience dealing with insurance companies and understand all the gotchas they are constantly coming up with, it would be impossible to really know how flawed many of the policies are. (For that matter, the Navigators don’t seem to know much either, but that’s probably a feature not a bug.) The idea that un-insured, many of whom leading struggling and stressed lives, will be able to choose a plan that’s good for them is something only Heritage could have dreamed up. I’m duly impressed that so many people are choosing `none of the above’.

Conclusion

Ladies and gentlemen, I present our health care system, and those who use it, Seven years after ObamaCare was passed. And a case study that shows what could be.

About Lambert Strether

Readers, I have had a correspondent characterize my views as realistic cynical. Let me briefly explain them. I believe in universal programs that provide concrete material benefits, especially to the working class. Medicare for All is the prime example, but tuition-free college and a Post Office Bank also fall under this heading. So do a Jobs Guarantee and a Debt Jubilee. Clearly, neither liberal Democrats nor conservative Republicans can deliver on such programs, because the two are different flavors of neoliberalism (“Because markets”). I don’t much care about the “ism” that delivers the benefits, although whichever one does have to put common humanity first, as opposed to markets. Could be a second FDR saving capitalism, democratic socialism leashing and collaring it, or communism razing it. I don’t much care, as long as the benefits are delivered.
To me, the key issue — and this is why Medicare for All is always first with me — is the tens of thousands of excess “deaths from despair,” as described by the Case-Deaton study, and other recent studies. That enormous body count makes Medicare for All, at the very least, a moral and strategic imperative. And that level of suffering and organic damage makes the concerns of identity politics — even the worthy fight to help the refugees Bush, Obama, and Clinton’s wars created — bright shiny objects by comparison. Hence my frustration with the news flow — currently in my view the swirling intersection of two, separate Shock Doctrine campaigns, one by the Administration, and the other by out-of-power liberals and their allies in the State and in the press — a news flow that constantly forces me to focus on matters that I regard as of secondary importance to the excess deaths. What kind of political economy is it that halts or even reverses the increases in life expectancy that civilized societies have achieved? I am also very hopeful that the continuing destruction of both party establishments will open the space for voices supporting programs similar to those I have listed; let’s call such voices “the left.” Volatility creates opportunity, especially if the Democrat establishment, which puts markets first and opposes all such programs, isn’t allowed to get back into the saddle. Eyes on the prize! I love the tactical level, and secretly love even the horse race, since I’ve been blogging about it daily for fourteen years, but everything I write has this perspective at the back of it.

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134 comments

Belgium is socialist, the USA is capitalist. The different healthcare systems couldn’t be more different as a consequence. Wanting to have a Belgian healthcare system, in a capitalist country, is self-contradictory. I don’t see the USA becoming less capitalist anytime soon.

About 64% of U.S. healthcare is funded by the Government (if you include the employer tax deduction for providing employee health insurance). The total amount exceeds per capita what governments pay in every other civilized country to cover every citizen. The 36% private funding make up excessive profits for private insurance, Big Pharma and the rest of the healthcare industrial complex.

Agreed! And this canard is a favorite of those who either do not understand or seek to obfuscate the US healthcare “system.” A corollary is that if we had “real competition” healthcare prices would be comparable to or lower than other societies.

which discussed the story of the RUC. This led to a reference of a suit brought against the CMS for the way it let the AMA set the PFS….Physician Fee Schedule.
The court case was dismissed because Congress: (I’ll let the court explain:)

According to the Complaint, RUC has met each year since 1991 to “debate relative values based upon input from surveys distributed to specialty societies.” Compl. ¶ 45. RUC then makes recommendations to the Secretary of HHS. Although Plaintiffs acknowledge that the Secretary rejects some of those recommendations, see id. ¶ 71, Plaintiffs assert that most RUC recommendations are routinely
adopted into the final PFS.
Accepting as true that RUC plays a major role in the
formation of the PFS and also accepting as true that this role
unfairly skews the PFS toward certain medical professions and procedures, the Court, nonetheless, finds that Congress has precluded courts from reviewing, not only the final relative values and RVUs, but also the method by which those values and units are generated. Section 1395w-4(i)(1) of Section 42 of the United States Code provides:There shall be no administrative or judicial review
under section 1395ff of this title or otherwise of–
(A) the determination of the adjusted historical
payment basis (as defined in subsection (a)(2)(D)(i)
of this section),
(B) the determination of relative values and relative
value units under subsection (c) of this section,
including adjustments under subsections (c)(2)(F),
(c)(2)(H), and (c)(2)(I) of this section and section
Case 1:11-cv-02191-WMN Document 19 Filed 05/09/12 Page 5 of 15
6
13515(b) of the Omnibus Budget Reconciliation Act of
1993,
(C) the determination of conversion factors under
subsection (d) of this section, including without
limitation a prospective redetermination of the
sustainable growth rates for any or all previous
fiscal years,
(D) the establishment of geographic adjustment factors
under subsection (e) of this section, and
(E) the establishment of the system for the coding of
physicians’ services under this section.
42 U.S.C. § 1395w-4(i)(1) (emphasis added).
Several courts have examined this prohibition on judicial
review in the context of challenges similar to that presented by
Plaintiffs here. In American Society of Cataract and Refractive
Surgery v. Thompson, 279 F.3d 447 (7
th
Cir. 2002),

Belgium is part of a monetary union, the eurozone (dark blue), and of the EU single market.
Belgium’s strongly globalized economy[82] and its transport infrastructure are integrated with the rest of Europe. Its location at the heart of a highly industrialized region helped make it the world’s 15th largest trading nation in 2007.[83][84] The economy is characterized by a highly productive work force, high GNP and high exports per capita.[85] Belgium’s main imports are raw materials, machinery and equipment, chemicals, raw diamonds, pharmaceuticals, foodstuffs, transportation equipment, and oil products. Its main exports are machinery and equipment, chemicals, finished diamonds, metals and metal products, and foodstuffs.[29]

as capitalistic as it gets
taking care of your population being healthy helps them being productive and assures a longer life
just being a citizen of belgium makes that you are entitled to healthcare (rijksregistergerechtigd)
below a certain income your part of the bill is reduced to really low amounts
groin hernia operation with implant 3 euro

Belgium has enough privately owned profit-earning farms, factories, etc. to where it could be called capitalist. So that means a capitalist-economy country can have a decent health care system. And capitalist Canada has socialized the payments under CanadaCare.

agreed, the capitalism vs socialism argument is a canard but many Americans have been indoctrinated with the national “creed”. This creed is highly simplistic and misleading as is all propaganda but it works. Disturbed Voter you need to think a little more critically and independently.

My wife and I don’t have insurance. I live in Louisiana, am 33 years old and in good health. I am married with no children, an independent contractor making just under $100k. Post ACA I have often looked into my options for health insurance–thinking surely I will find something different this time. I always come away choking on just how bad the options really are. Given the high deductibles, these policies are really only catastrophic coverage if one is healthy. So I am being asked to pay nearly $10,000 a year for what is essentially just marginal insurance against bankruptcy. Any way I look at it the deal stinks. I will continue to role the dice until the equation changes. The system is truly extortionate.

My condolences. As an independent businessman, you are really between a rock and a hard place in the US in multiple ways. The majority of small businesses only break even, and only because they cheat on their taxes.

Yes, the affordable versions have high deductibles. The corporate plans have shifted over the last 2 years, to match the terms you find in the ACA options. My deductible has gone from $3K to $6K … as a single … for the same monthly “contribution”.

People can’t see with their own eyes. The SCOTUS declared the ACA is a tax. They didn’t declare it was heath insurance or health care. SCOTUS said it was a tax, even though Congress didn’t use that word in their “can’t know what is in it until we pass it” horror. So if you play ball, you are accepting a large regressive tax increase … disguised as government health insurance (if they wanted it to be government health insurance, it would be expanded Medicare). And per crony capitalism, favored private parties are at the pig trough. Purchase private health insurance if you can afford it, and leave ACA alone. At my advanced working age, if I only had ACA as an alternative, and couldn’t afford private insurance, I would choose voluntary poverty instead (how is that for stimulating the economy) and pay the corresponding tax penalty.

what are you talking about “buying private insurance”? there is no such thing it is all ACA now. And yes this whole thing is mainly a tax increase and welfare program. I agree with that. The one thing it is NOT is healthcare reform.

That’s not true – there is private insurance. My co-parent needed to get insurance while she was a contractor and didn’t have anything from her company. She looked on the exchange and found, HealthPartners I think, had the “best” for what she needed. She contacted HealthPartners directly (some web link ad on some web page said you could buy insurance without the hassle of the exchange) and bought the same plan for the same price. She worked directly with HealthPartners, directly sent them the check, and got her insurance stuff directly from them (the plan was presumably some public pool). That’s part of the feature-not-a-bug: now insurance companies encourage people to go outside the exchange by offering the same product without the hassle.

(They didn’t even make her sit through the rah-rah HDHP/HSA Show that every HR person has made me sit through at every job I’ve had in the last 10 years. I am kind of envious of her.)

The original justification for high-deductible plans, usually paired with Health savings Accounts, was that they incentivized people to shop around. Competing plans with lower deductibles required less shopping but had smaller networks.

Now, we have high deductibles AND narrow networks. So we are supposed to shop around, but we’re also unable to shop around because we often have few choices at any price.

As Mr. B. points out, insurers demand we all irrevocably sign up for a full year while reserving the right to change coverage, drug formularies and providers at any time.

This is Alice in Wonderland. It is completely unsustainable but I see one glimmer of hope. Insurers will have announced their 2017 plans and prices shortly before election day on Nov. 8. I fully expect them to twist the screws further, but a pre-election outcry might actually get some action. We’ll see.

yes, the theory is that high deductibles incentivize people to shop around, but that his just neoliberal bunk. Shop around for medical services! That is a bad joke. My son got a bone bruise last year playing hockey and we went to see the orthopedist. They wanted to take an x-ray but I wanted to know how much since our deductible is $5k. The injury seemed minor so I wan’t keen on incurring $500 in out of pocket costs. The doctor had no ideas so he asked the office manager who had no idea who asked the billing department who had no idea. This was a pretty major orthopedics practice in Stamford, CT and the billing people told us it is virtually impossible to know what will be billed for any given procedure in advance due to the number of plans in effect. They basically don’t know until they bill the carriers what is allowed.

So one of the core ideas behind the ACA is just neo-liberal economic nonnsense!

Its like nobody remembers how it was horrifying before “Obamacare” (which isn’t actually a health insurance plan you can buy…) when these folks had NO choice.

I have to take the one option I have from my Fortune 100 company. Its as crappy as any plan you’ve detailed. $6500 deductible. “Obamacare” has made the increases slow significantly. Jolly that, and not disasterous.

Lambert, this is becoming tiresome, along with the Hilary bashing, are you suggesting the way it was before was better? Poppiest of Cocks.

mdscry, I can understand your frustration at a crappy plan. What ACA has done for our family is not to provide care anywhere near affordable. Rather, we have to find workarounds, because if we were enrolled, we would have no money for actual health care.

What we have to do, to not pay a tax for no benefit, is to take a tax on time to avoid paying the fine. It is a position of privilege to have a crappy plan with the income to pay it. ACA has in fact made our life worse.

And please understand, in no way am I suggesting you did not work hard for your position. However, you may have avoided bad luck and the associated debt load that can come with it. A family of our acquaintance has a severely retarded child, and the debts associated with that meant loss of care. If your debts are high, and you work to pay them, higher income decreases the reimbursements under ACA. That’s a trap that does not have to be.

it was WAY better before Obama care. Unlike you, I know because I bought insurance in the individual insurance market for several years before the ACA came along. It certainly wasn’t better for those with pre-existing conditions that were effectively barred from getting insurance but for the rest of us the ACA has been a disaster.

The pro-Hillary, pro-Obamacare people usually have acceptable coverage from an employer and just want to feel like they solved the problem. It’s tiresome to them to hear that the problem has gotten worse for most of us. They don’t like us jostling their complacency.

But yes, the way before was actually better, at least for me. Even the parents in the comment above with the son with the kidney problems could have gotten him onto Medicaid. He’s a student with no money.

Now, if you choose to resist this predatory system by not signing up, you get fined. There was no fine before.

I’m self-employed. I never know what my income is going to be from year to year. Some years I qualify for Medicaid (though no doctors around here will accept it), others I don’t. I literally never know until the end of the year whether I’m going to qualify or not. One year after Medicaid-level income all year I suddenly got a consulting gig in late November that would have wiped out my Medicaid eligibility. I can’t afford to pay back subsidies etc when I may have no income at all the next year.

Not that I’m able to sign up anyway. The Nevada exchange was dysfunctional when it opened, but I made the mistake of trying to sign up. Now my social security number is in the system, but the password I created doesn’t work. I’m unable to get a new password, and I’m unable to open a different account, even after all this time, because my social security number is already in there on my first attempt at an account.

But I’ve decided that was a gift from God. I’ve gone without health insurance my entire life, and that meant I had to learn to take care of myself properly and avoid unnecessary risk. I wear my seat belt. I cross the street carefully. I know more about optimal nutrition and food toxins than any doctor I’ve ever met. I’ve learned to become an excellent healer for myself and my family.

No one in my family has high blood pressure, high cholesterol, autoimmune diseases, heart arrhythmia, gallstones, diabetes or pre-diabetes, because every time they’ve headed that way I’ve healed them with proper nutrition.

If I got cancer or something like that, I wouldn’t use the predatory U.S. medical-industrial complex anyway.

If I get shot by some moron, I’ll inform the hospital that I don’t have insurance and they will kick me out asap. If the bill is still too high, I’ll go bankrupt and stick the system with the bill, happy in the knowledge that I will have contributed to bringing it down.

Disturbed voter is confused. Belgium is a democracy. Most European countries are “democracies” (as the term is commonly and rather loosely employed). The U.S. ALSO is a democracy, at least in the minds of its citizens/consumers. And all of the above are CAPITALIST democracies, including Belgium, make no mistake.

The big difference is that in some countries healthcare and education are still not considered commodities and are not bought and sold on the stock exchange and are not subject to market forces driven by the greed of CEOs and the investor class – yet.

Yes they are still capitalist, thus they are still destroying the planet etc. – all those things that are part and parcel of the capitalist mode of production. But life is better for citizens in them at the moment.

Bravo … not in the Matrix are you! There is nothing wrong with collectivism or individualism … except for the people involved. I favor a mixed economy myself, and health care per President Truman (when we still had a New Deal) and MIC per President Eisenhower. But that ship has sailed.

In socialism, you get someone else to pay for the stuff you need … and sometimes for what you want … depending on where you stand in the nomenklatura. The EUSA in Brussels … is the problem, not the King of Belgium. The EUSA is anti-democratic and USSR lite.

ah, whereas in kapitalism, we have the honor of us 99% paying for the stuff the 1% desire on a whim, not really ‘need’…
not like that awful socialism where all benefit from most contributing… *yuck*, who wants that ? ? ?

(so, 99% contributing and 1% getting virtually all the ‘stuff’ is great; but 90% contributing and 100% getting all the ‘stuff’ is not great… greedtard…)

In an otherwise informative account, Helmholtz Watson is simply mistaken when he writes “As for all the poor people who can now supposedly afford insurance, well that is a load of BS propaganda. There is no way most families can afford these plans even if they get a “subsidy”. And with $5k deductible most people avoid going to the doctor under these plans.”

At least in some regions, Obamacare plans can offer free or near-free coverage to those with incomes up to 2 times the poverty level, thanks to cost-sharing subsidies (in addition to premium subsidies). This is true, for example, in the NYC region. A single person making less than $17600 will pay no premiums, no deductibles and very few (and very low) copays, mostly for drugs. And the network appears to be fairly robust (though one never knows for sure in advance).

Of course, the same caveats which apply to the American health insurance market generally apply here as well — not all services may be covered, etc.

Agreed. My wife and I have a bronze plan – basically catastrophic coverage with $4000 deductible each – which is $875 a month before subsidy and $312 a month after subsidy. But before the ACA she couldn;t buy insurance as she has a pre-existing condition.

Overall, a significant improvement for us, at least since we both left corporate jobs with benefits for self-employment.

Let’s not throw the baby out with the bathwater.

However, we are both Sanders supporters. SIngle payer ends the predatory casino of greed.

not aware that anyone can get a plan with no deductibles. I have never seen such a thing when I shopped for plans. Even if that is right, someone making less than 17,600 in the NYC region has got problems well beyond medical insurance because with that type of income they are probably living under a freeeway overpass and rummaging through dumpsters for food, but hey they have healthcare! Oh Great!

…something that people in the NYC region with 10x that income can’t manage. And good luck finding a place where real estate taxes and maintenance are manageable on $1467/mo.

Meanwhile, I see little reason to design social policy around subsidizing people who are cash-poor with million-dollar assets. (Not that NYC’s “low-income” housing market isn’t centered on that already.)

An anecdote: In 1991, my son was born in Green Bay, WI, and we did not have insurance covering the pregnancy. I called the hospital a few months out and asked how much the delivery and hospital stay would cost. It was a flat fee of $1,850, unless there were unexpected complications. My wife only needed to stay in the hospital for one night. The bill–just as promised-$1,850. I can’t imagine ever getting a hospital to quote a fixed price for any procedure today.

Since the early ’90’s, I have purchased private health insurance for my family. As with everyone else, I have experienced huge increases in premiums that always outpaced inflation. Combined with higher premiums came higher deductibles, copays and total out of pocket charges. In network, out of network, took off, along with exclusions and out right denials for preexisting conditions.

Last year my wife and I spent 3 and 1/2 months traveling Europe. Each month, I wrote a check for $1,300 for U.S. health insurance, knowing I would never use it. $4,500 down the drain for absolutely nothing. And had we needed healthcare in Europe, of course our insurance would not pay a dime.

While in Denmark, our bicycle tour guide boasted with pride if any foreigners were injured necessitating emergency care, we would receive free care because it was an emergency. He did not begrudge the state paying for our care as would be the case in the U.S., in which free care for a foreigner would be laughed at.

Traveling through 11 European countries, it is obvious the healthcare industry dominates our economy. First, you never see a t.v. or print ad hawking the latest, greatest drug. Second, you barely even notice hospitals or other medical service enterprises. They are there, but not in your face as when you travel around the U.S.

The problem with U.S. healthcare is very simple. We charge way too much for doctor visits. France is about $40, depending on the exchange rate, which is more than many people’s insurance deductibles. They reimburse 70% of that amount and you can buy additional insurance if you like. In France, prices are transparent and regulated. No one would accept what happens to us in the States where a call for pricing to a doctor or hospital is seen as an unreasonable request. Finally, drug prices are negotiated and profits for private health insurance limited.

In the U.S., the patient is seen as a pawn for the profit seeking medical industry to exploit. In France, the patient is to be healed and made better.

Why so many Americans accept our dysfunctional healthcare system is beyond me. But as with most things American, until the individual actually experiences dysfunction first hand, she does not believe it. And since so many still get private insurance through their employers, too many are complacent.

Moral of the story–if you want to spend less and get more, any place other than the U.S. is where you want to live.

While in Denmark, our bicycle tour guide boasted with pride if any foreigners were injured necessitating emergency care, we would receive free care because it was an emergency.

My parents had a car accident in New Zealand. Three weeks in hospital for my mom, surgery for a broken back, fitting a torso cast plus two more weeks of outpatient physical therapy and the out of pocket was $100 for the crutches she took home.
Thanks again kiwis for having a civilized country. I’m sorry we can’t offer the same when you visit us.

There is another aspect to the crapification and increasing costs of private health insurance. It is strangling our public institutions. For instance, there was much publicity for an announcement by the Chancellor at UC Berkeley regarding a systematic budget deficit that will require painful concessions/cuts. Some portion of the deficit is administrative bloat, but one portion of the deficit that has received little attention is health care costs. The cost of providing health care to employees has increased so much, it is starting to strangle the finances of UC Berkeley.

The health insurance path our nation is currently on is not sustainable, and something will have to change. Hopefully it will be a move to single-payer. The health savings accounts being pushed by the Republicans is nonsense. It would be the 401k-ification of health care.

The accounting of medical costs varies from country to country although I don’t think the accounting is enough to explain the higher pricing in the United States fully. But I’ll give a couple examples: doctors (and nurses and etc.) in the United States have typically paid for their own medical education in great measure. At least some part of every service fee is going to pay for that education. This education in France is nearly free for qualified applicants so the same costs are found on the budget of the French education ministry. Likewise if you study the prominent construction project signs in front of hospitals under construction in France you’ll note that such projects are very likely to be bookkept against national infrastructure budgets within the Health ministry (or even some other unlikely place). Again, service fees in the United States are amortizing these investments pretty fully, while only partially in France (because the bulk of it is an infrastructure investment budgeted as such). Anyway, the gaps close down some if typical US accounting would be applied to some of these other systems – but not totally for sure.

Very old data, but perhaps indicative. I was dating a nurse back in 1986. This is in Ontario, Canada, when the govt of the time was Conservative (the odious Bill Davis) and had called freeze on hospital staff hiring. So.

Starting salary for an RN at that time was $37k, same as a starting police officer here. But, no full-time jobs available, only contract work thru temp agencies, which paid the same but didn’t have the bennies or stability. Note: payroll expenses were counted as payroll, but payments to temp agencies which were cost plus the agencies’ profit did not count as payroll, so the hosps could claim they were cutting ‘payroll’ costs. Amazing!!

My bf looked into other opportunities. Saudi Arabia was recruiting and looked very good, $$$-wise, esp he being a guy, but not all that pleasant overall. The recruiters promised 6 to 8 week long tours, enlivened by trips to ski, screw and drink in Switzerland. Most of his graduating class was ladies, so presumably the pitch was to them.

But here is the kicker: He could have gotten a job just over the border in New York, where he had in fact been born, so green card not a problem, and started at a huge $14,000. Where is all the money* going?

*Note: US spends more per capital than *anybody*, gets worse results and millions not covered.

If you look at the US, we are running on brand fumes. I’m reading a book now that describes how the US’s high level of educational attainment is due to having highly educated older people, when the US was clearly better than the rest of the world. If you slice the stats by young people, the US is middle of the road at best. And that’s before you factor in the fact that our educational costs in GDP terms are, like those of our health care systems, excessive relative to the end result, due to the explosion of higher educational costs.

Agreed. Beyond the general decline, what struck me most on my return visits to the USA is that the disparity in the quality of education has spread beyond the ghetto and into large swaths of middle class, often with the cooperation of the Middle Class**.

Even Public school systems now actively promote “magnet schools” which suck the best and the brightest out of community schools, so that teachers in the later can teach down, students are deprived of a chance to self-check and emulate better performing students, etc.

**ie: Integration academies, which sprung up across the south and even parts of the Middle and North. where parents willingly pay for a sub-standard education as long as it keeps their child away from blacks and dark-skinned Hispanics.

It’s basically just a big circle jerk, eric377, First the fire sector offers no doc/low doc loans to teenagers for college, saying to them “the only way to get ahead is college, we’re shipping all the other jobs overseas in order to crush labor here, TINA” These sub-prime loans (conveniently backstopped by the gov’t) drive up the price of college, and of rentals near colleges, which things of make the fire sector more money. Then the services you mention become more expensive so people have to put more money in the fire sector to pay for them. Then one can’t perform these expensive services just anywhere, so the fire sector floats a bond deal to re-face one facility or another, once again benefiting the fire sector by amortizing these fees into goldman sachs’ balance sheet. Too bad France hasn’t figured out how great GS is or they could be in the same predicament that we are…but don’t worry, they’re pretty well represented in brussels so i’m sure they’ll weasel their way in eventually and we can talk about how crappy it is everywhere in the world because accounting

Yeah, but I dont follow the MSM, dont own no TV. My worldview is hopelessly biased by apocalyptic blogs like this one. If I become depressive, I will sue NC for not respecting the fairness doctrine and coloring the world in such despairing tones.

Merf56 above presented a very powerful story of someone who was helped by the ACA. Single payer would improve on the situation but no question there are some people it has helped, or in the case of his/her family, saved. So there’s that.

There are also other people who are worse off. Free health care for all would be the best thing for everyone. Or at least free crisis health care with a limited # of free check ups, if you are that worried about hypochondriacs & people who are so frighteningly bored they wanna go sit in a doctors office to be bored there just for the hell of it, but then that gets into “which things are covered under free crisis health care” etc. & there aren’t that many people wanna go doctor for fun, so just free 4 all imo.

The ‘balanced’ doctrine was presented as a good replacement for the ‘fairness doctrine’, which it was not. Per Wikipedia:
“The Fairness Doctrine was a policy of the United States Federal Communications Commission (FCC), introduced in 1949, that required the holders of broadcast licenses both to present controversial issues of public importance and to do so in a manner that was—in the Commission’s view—honest, equitable, and balanced. The FCC eliminated the Doctrine in 1987, and in August 2011 the FCC formally removed the language that implemented the Doctrine.[1]”

The ‘balanced’ doctrine doesn’t include honest or equitable. See FOX news. The ‘Flat Earthers’ love the ‘balanced’ doctrine.

Yes, exactly! Fairness as defined by the Oligarchy’s stooges on the FCC board.

All these words, Fairness，Balance, Transparent”, ad nauseam. are just tools of the propaganda, a little KY Jell to make inserting the phallic wrapped virus a bit less obvious, even more pleasurable to our bias.

Any good education should make one’s ears prick-up, give a tingle of warning when these words are run up any flag pole. “That point of self-education which consists in teaching the mind to resist its desires and inclinations, until they are proved to be right, is the most important of all.” Michael Faraday

Probably because not everyone can perfectly estimate their income so as not to get a refund (really depends on how predictable one’s income is – but I could see a lot of people estimating they would not get a refund and qualifying for one and having the penalty taken out).

Well, if you underestimate the penalty the IRS sends you a nasty note threatening to do more than send a nasty note same as if you don’t pay your other taxes (see: last year, this happened) and at least last year this amount was fairly trivial. Pick your battles etc. This year the penalty will be a LOT higher but I’m guessing they plan to just take it plus further penalties if you don’t pay up.

It wasn’t just the insurance companies who got a bailout with the passage of ACA., Pharma and private medical groups got one as well.
Because ACA was written by lobbyists for those groups, it was always destined to be a disaster. You see, they took an expensive system that still worked and systematically removed everything in it that made it work. Price Controls being one of the largest pieces, but also real regulatory teeth regarding coverage, networks, and sensible deductions and out of pocket maximums.
Provider costs should never be determined by the insurance companies or the providers themselves. You walk into a doctors office, their prices should be on the wall. You go to a hospital and the cost of an appendectomy without complications should be readily available. And you should never have to figure out what a drug costs. If ACA were to work, that needed to be the case and required by law in America. The minimum size of a ‘network’ should have been specified. No changes in network in a coverage year unless the doctor dies or moves out of the area. Pharma being hog tied and limited, for instance no more of the ridiculous extensions of patent because the delivery system is changed or a rearrangement of inert ingredients.

I feel for the person above with the son with ongoing medical issues. But unless they can tell me how our political establishment will be able to rewrite ACA to include all the things that the lobbyists took out, there is no saving or improving ACA. Single Payer may be pie in the sky, but incremental changes will still leave an ever growing portion of this country not getting any benefit from their health care coverage after laying out tens of thousands dollars every year. And more and more people opting to either pay or avoid the fine. ACA is a drain on our economy, a danger to our overall national health, and doesn’t even stop the problem of medical bankruptcies and hospitals with unpaid bills.

We were traveling outside of the United States over the holidays. I got a severe sinus infection that required a visit to the doctor. I got an appointment at the local clinic for that afternoon. I saw a nurse and an intern followed by the doctor who prescribed a steroid nasal spray and amoxicillin. Doctors visit was $70. At the pharmacy, the prescriptions came to $25 (the nasal spray being the most expensive item)

I am really surprised that some enterprising capitalist has not yet come up with a super cheap insurance plan with an astronomical deductible basically as a way to make pure profit knowing the company will rarely pay out for claims.

*ahem*
have you been paying attention (not to mention premiums) ?
that is effectively what is happening, just in a boil-the-frog manner, not all at once…

i am one who railed profanely at the insanely priced/no coverage/huge deductible ‘plans’ (the ‘plan’ is for the 1% to separate as much of your money from you as possible), and have lucked out in that my employer has free health insurance…

have NO IDEA how ‘good’ it is, and kind of don’t care… if i can use that to shield me against the obamacare taxation without medication, then that is good enough…

in general, been lucky and/or genetically fortunate and/or take care of myself enough, that i have had few medical issues in my life; but age and the odds are bound to catch up with me and/or SWMBO, and then the fun begins…

BUT the downside is, OF COURSE we won’t go and do physicals, tests, checkups on suspicious body hiccups, etc, because 1. costs are unknown, except, 2. it WILL be WAY more than we can afford…
EVERYONE knows preventative medicine is approximately a zillion times more effective and economical than dealing with issues that have festered; yet there is essentially NO WAY to get that kind of CARE under the present system, UNLESS you are a multi-millionaire who can pay that out of your couch change…

as i said before, the ACA has NOTHING to do with promoting better healthcare for the public, and EVERYTHING to do with ripping us off to the max…

(not to mention establishing an horrific precedent by the tax penalty for NOT buying services deemed mandatory by the gummint… stupid libtards (mostly) conveniently elide this oh-so-minor point, ’cause they are blinded by their lust to promote the ACA as some super-liberal victory when it is the complete opposite…)

Or you qualify for Medicare and put a supplemental plan on top of it. In Massachusetts that would run you $140 a month and you pay $20 for a Primary Care Physician visit (no limit) or $30 for a Specialist
Most of the people on this thread should move to another state

My fiance Mike has been denied disability twice. He has bleeding in both eyes and may go blind. He cannot afford the surgery. If he does go blind-that will cost the taxpayers more. One doctor in Austin, Texas saved his feet from amputation twice and did not charge one dime. How is that for a surprise?

Last year, my wife and I tried to load all our medical procedures into a single year in the vain attempt to meet our deductible. Most people would consider all medical expenses ordered by their treating physician to be true out of pocket expenses up to their deductible. Not United Healthcare. They applied some sort of sliding scale to consider 3 out of every 10 dollars spent as ‘not applied’ to the deductible. No explanation. Now when you’re talking about close to $2,000 on top of what is supposed to be the ‘deductible’, I thought a reasonable inquiry was in order.

After 4 letters; 2 insurance department complaints; and a half dozen e-mails and phone calls, I still do not have an explanation. I’m not even disputing the amount mind you, I just want to know how they have arrived at the sliding scale. The fact that I am an insurance coverage attorney makes it even more frustrating because I know I’m using the correct lingo and pressure points.

The only reasonable explanation is that they just don’t give a sh*t, and I’m not big enough to make this a true problem for them.

Have you called your local legislators? They have been dealing with the madness that is ACA which is part of the reason Democrats don’t really talk about it anymore. They know ACA is a disaster, and if Hillary wasn’t on the ballot, I wouldn’t be shocked to see Democrats railing against it.

when the ACA kicked in I was in such a state of shock I harangued my congressman’s office, Jim Himes of CT. I eventually got a meeting with some the kids who staff his office in CT and it was worse than a waste of time. Demanded calls with the legislative aids for both senators and Himes. Nobody wanted to talk about it and they basically apologized so you are right the Dems don’t want to talk about it. The things that drives me nuts is people like the NYT and Paul Krugam who endlessly proselytize in favor of it, although the NYT has run a handful of articles that discuss the reality.

Lots of my more democratic rah rah friends are always amazed that Democrats don’t run on the ACA. I’m pretty damn sure that most of the Dems who still have an elected position are well aware that deep down that is a loser that is only going to get worse. I’m pretty sure they were sold on the whole it isn’t going to change much for people with insurance but people who don’t will now get insurance. Sure it will be expensive for some but everyone who can’t really afford it will get help. Instead they found a mess where the insurance companies used every loophole possible to provide little or no care, high premiums and outrageous deductibles. And that the government provided little or no regulation to rein them in. IOW, I’m pretty sure the rank and file elected official has been as gob-smacked as most of us at how bad this has been. Sure, unlike them I knew it would be bad, but the level is really mind blowing, the insurance companies aren’t even pretending to offer anything but expensive catastrophic coverage.

Wow! Looks like my only options are bankruptcy (again) or death. Because I’m not going to give up being an Artist.
People think that Trump is bad. Can’t wait to see what type of leader is generated from this evil. I have to go calm down now.

I have low end individual coverage from Anthem for myself and family (4 of us). We have a pre-ACA policy which our agent recommended we hold on to. It goes up about 15% each year, and we are up to $900 / month, with 2250 deductible, but when I check offerings online, they are more for higher deductibles. I see from other comments that this is a relatively good policy. It is hard to see that the situation is sustainable though. Though I seem to have lucked into one of the better policies, pretty soon I’ll be paying more for health insurance than for my monthly mortgage on a modest home.

Anyway, the thing is, when it comes to pharmaceuticals, it does not do well. I recently went to a dermatologist and got a prescription for calcipotriene. It was $775 at the local pharmacy for a 60g tube! I found it online from abroad for $50, out of pocket of course. So much for insurance. Meanwhile, a high school friend who has a pretty good wealthier persons policy (pre-ACA I assume) pays $7 per tube. Needless to say, of course someone who is paying $7 is not going to think the system is broken. I figure most of the wealthier are in this boat. But the number of people who are not in a large company or institution’s policy, and not independently wealthy are getting squeezed…

I’ve lived in Belgium for the past 20 years The health care system is brilliant but I would not at all label it single-payer plus. Single-payer to me is like the NHS is Britain or the system in Canada where there is one main government system with the possibility to buy private supplemental insurance. That is not Belgium. Here it is a total confusing web of private and public hospitals, different insurance companies, price transparency, and best of all, a myriad of really, really good choices.

Our insurance is through my wife’s international agency employer and so is not typical in Belgium. Normally for small things we have to pay upfront and then get reimbursed 80%. There is a limit of 2000 euros a year of out of pocket expenses. No deductibles. We typically get “over served” since they think (mistakenly) that we have a posh insurance. Once when our twins were tiny and one had a fever, my wife went in with both because she was still nursing. They never touched one of the twins but when the bill came in there was 10,000 euros of charges for all kinds of imagined things the hospital never performed on them. But we called and explained it was total BS and they replied, “what do you care”. When we explained we pay 20% they quickly redid the bill correctly!

For major medical issues the insurance company gives an open account to the hospital to cover all costs. Due to the nature of my wife’s international organization they pay 20% above the normal fees for the hospital’s research funds.

Unfortunately we have had to use the Belgian health care system quite bit over the past couple years. Our most recent situation I think will show the superiority of a mixed system over a single-payer – although obviously for Americans, any universal system is better than what currently exists.

My child was diagnosed with a tumor that could potentially be bone cancer and within a half hour a world class orthopedic surgeon – with years of experience at a rather well know elite New York cancer hospital (I want to stay a little vague) — was calling us to set up an appointment. At the time we were hopeful the tumor was not malignant but it was a pretty strong signal when a guy like that calls you that the tumor is not benign.

Of course he was an expert at saving limbs, etc so we went with him. Besides we were in a total state of chock and I knew very little about the in and outs of cancer. For the chemo we chose a public children’s hospital on the other side of town. In Belgium there are two main university hospital systems, that actually mirror the education system: a more elite Catholic (in name only) system (the hospitals are named after saints) and a public system that must accept everyone — paying or not. On top of this there is a for-profit private system that specializes in profitable interventions. Typically you are covered in all three systems so the patient decides and prices are transparent (for cases where the payment is not 100%). We had a brilliant Catholic hospital ten minutes from out house but they were not specialized for children and sleeping over there was a nightmare. The rooms in the public hospital were designed with a bed for the parents (and a good wifi system!)

The oncologist warned me that they were a public hospital so they could turn no one away and so the clientel were nowhere near as posh as the hospital near my house. And indeed the lobby looked more like a souk in Marrakesh than a hospital in Belgium. But the parents were all in the same boat, at least on our floor, and that counts much more than cultural differences.

In hindsight our oncologist had been signaling me from the get-go to dump our surgeon. Sure despite his website being full of limb-saving devices the situation morphed into dramatic clearings of the room and one-on-one sessions with me (the decider) on the benefits of amputation. Luckily for me I finally read the smoke signals my oncologist had been sending and went to get a second opinion. The stereotype in Europe is of long waiting lists. We went to see the new surgeon on a Tuesday (I had emailed her on the Sunday night before), the situation was complicated and urgent (the other surgeon had run the clock out on me to pressure me into the amputation) but in my head I came up with an rather innovative solution to expedite things (normally there is a long lead time). After months of dithering from by our former surgeon, the new one totally bought in to my plan and she agreed to do the limb-saving intervention nine days later with an off the shelf item. My child is currently exercising on the treadmill trying to minimize their limp.

The key difference between a single-payer and a mixed system is flexibility of choice by the patient and profit by the doctors. In a single-payer system there is no profit motive and things quickly become bureaucratic. In a mixed system doctors need to bring in patients and in my situation at least, having options meant the difference between an amputation and saving a child’s limb.

He was a European working in New York. Top European doctors like to perform a couple years of slavery in elite US hospitals before returning to a normal life in Europe. He met his Belgian wife there, who is an even heavier hitter in the cancer world than he is. They decided they wanted to raise their children in Europe so they moved to Belgium since her career was more important than his. The US probably retains the top visiting doctors who end up not having children.

“Our most recent situation I think will show the superiority of a mixed system over a single-payer – although obviously for Americans, any universal system is better than what currently exists.”

Well, no, it didn’t. I live in Canada where we can get second, third or more opinions, w/o extra charge. Granted, they treat chiropractors, naturopaths and homeopaths as kinda sketchy, but that may change. I don’t think our system in Canada is perfect, I would love to see prescriptions, ophthalmic and dental covered, just as a start, but how does your anecdote demonstrate ‘superiority’?

I live in Canada too. “there is no profit motive and things quickly become bureaucratic” Huh? I get my medical services plan bill and pay it. It’s a reasonable rate. When I need medical help I go to my doctor. If I want more information I go to another doctor or get referred to a specialist. No worries about “networks.” I show them the BC issued card that shows I’m part of the medical services plan. I get treatment. I don’t worry about deductibles, looking for plans among a confusing mess of options (most of them apparently bad) or whether I can afford to go for treatment. My fiancee’s father just had heart surgery. He had lots of things to be concerned with but drowning in paperwork wasn’t one of them. Seems like it’s the U.S. model that’s smothered in bureaucracy. Given the advantages in population, population density and distribution that the U.S. has I suspect that you would be able to do rather better than Canada does if you went to a single payer system. You could probably get significantly better health care while spending less than half of what you spend now per capita.

Some citizens DO benefit from ACA, such as the person, above, with the son with kidney disease. I am always glad to hear such stories.

But time and again, the preponderance of stories is how insanely expensive and crappy things have gotten, while we all know (without searching out the stats) that the real winners in this rip off system are the Fat Cats in BigIns, BigPharma, BigHospital, etc., with their giant “salaries,” benefits, perks, etc.

I get what used to be good health care insurance via work, which is large group health ins plan, and so, should provide decent benefits. Like everyone else, my premiums continue to rise, along with deductibles, and coverage grows ever sparser. As I’m getting older, there are certain tests and procedures that I need now, which I didn’t need when younger. These used to be fully covered, as they’re pretty standard & not something fancy or out of the ordinary. Nowadays, I can count on having to pay for some or all of these procedures for who knows what reason. It just IS.

I am fortunate to be able to pay for these “extras,” but as I’ve stated on this blog before, I plan to continue working, if I can, into my 70s. Part of me just wants to; I’m healthy; I am lucky enough to have an enjoyable job that I can do at may age. But I’m also doing it in order to cover my medical costs for as long as I can. I know as I age, it’ll just get worse and more expensive.

The outcome is that someone younger down the ladder will have to wait longer for me to retire so that they can be promoted. I’m sorry for that reality, but I have to look out for myself, in this case.

It’s a racket. Calling your insurance company to get answers is a mug’s game. The only answer is this: the PTB are robbing you because they can. In this case, I do have to say: Thanks, Obama. You didn’t even TRY to get something better. You sold us out to the fat cats. Guess you got YOURS. So screw the proles, per usual.

If it’s apparent that the ACA is worse than useless, and, if the penalty can only be applied to funds one might receive via ones’ tax REFUND, as I understand the mandate, then why are people paying the supposed penalty, if it is unenforable? Is it fear of an IRS audit? Is it just a Pavlovian response? Why are people paying penalties for utterly useless garbage??

I recall Yves wrote an article, that the ACA Individual Mandate from the current yr, is garnishable from ANY refund over the NEXT 10 yrs. Also, if it gets garnished in a future year, they will apply an IRS interest rate, higher than the CPI inflation rate (iirc 3.3% at the time of the article when CPI was ~2%).

So to avoid paying the ACA Individual Mandate, you have to never receive a refund for the next 10 yrs. IMHO to accomplish this, you are paying a tax on time to avoid a tax on money.

I recall reading that more USians file taxes via outsourcing a tax preparer, than doing it themselves. As such, I would guesstimate that those who outsource may only look at the “bottom line” of the amount of the refund/owe, & may not realize if the ACA Individual Mandate extorted off part of the refund.

Ah!……the E-word!!…….this is what the ACA really is…..Extortion….. plain and simple, to continue the whole corrupt pus-bag of Big Medi-Pharma-Insurance Fraud, and I refuse to be goaded into participating or condoning it !!!

This is, I feel, a big part of what has woken-up the public as to the venal aspects of both legacy parties…….and why they’re gravitating towards voting for Brand X instead of brands R or D.

“I would guesstimate that those who outsource may only look at the “bottom line” of the amount of the refund/owe, & may not realize if the ACA Individual Mandate extorted off part of the refund.”

Unlikely, IMO. Most people have preconceived expectations about said “bottom line” based on their experience in previous years. If the bottom line turns out to be materially different than what they were expecting, most would ask their tax preparer why. And tax preparers would likely volunteer the info without being asked because taxpayers tend to get ornery when this year’s bottom line is unexpectedly much worse than last year’s.

Please keep this comment section open long enough to give me (and others, I presume) long enough to put pen to paper the personal disasterous ObamaCare narrative we have been composing in our head (s).

You may be performing a second public service to your stated one -by providing an outlet to relieve the stress produced by the feelings of fury/ powerlessness provoked by skyrocketing deductibles, co-pays, and premiums – all coupled with stunning and arbitrary losses in coverage, especially for pharmaceuticals (not talking simply about being forced into generics).

The by today’s standards ridiculously cheep policy my USA under-graduate university offered in 1970’s also had no deductibles. There was a 5 dollar co-pay, waived for those on a Pell Grant (does the USA even still have Pell Grants?) This included the medicine, picked up from the same clinic’s dispensary. The downside is we often were mauled by the medical students and their instructors, and the thought of being teaching material while under anesthetic not much fun These examples is just to point out the whole system over time has been perverted in the extreme, it’s applying car insurance think to health, and as the earlier example points out, is a just one marker of a process of crapification.

wonder if Skynet will object/hold up a post with a link to nakedcapitalism.

I live in Canada. I hear and live stories from the US — my relatives, old friends, the notices on the bulletin boards at the MI grocery store, “BBQ/Bakesale/Poker Run (true!) to Benefit 8 year old Blah Blahson who broke his leg/fell into a fire/has cancer/what have you. Here in Canada we spend 60 cents *total* to every dollar USians spend on health care/insurance/yada. Young Blahson would be *covered* here. There are no networks, no deductibles, no co-pays. And we still have insurance companies, and they are still making money. Just not on basic health insurance. Oh, and we still have people becoming doctors and nurses.

How can this be? The US is a country that understands vicerally, or should, that volume = lower price. I mean, ever heard of Walmart? Or an example I often use, Costco. What if there were BIG buying club for medical care? For prescription drugs? That is (one thing) a government is.

There is a specific segment of the population that gets hit badly by Obamacare. Namely, ones who are middle to upper-middle class, self-employed or in a small business, and are generally healthy. That’s a triple whammy because you don’t qualify for subsidies, are locked out of the group insurance market and must go on the individual market aka Obamacare, and face higher premiums because insurance companies can no longer screen for pre-existing conditions (which lowers premiums for healthy people).

To add to this expected downside, Obamacare has led to crappy insurance for which there is no reason except insurance companies can get away with it. That is, there is no specific reason why insurance companies can’t have wide networks like their traditional plans except that, since everyone is mandated to buy anyway, there’s no incentive to be better than your competitors. This has led to a race to the bottom, with crappier and crappier coverage being offered, knowing that your customer base is captive.

If you look at insurance objectively, most Obamacare plans are worse than medicaid (in terms of deductibles, OOP expenses, and even networks of physicians and access to care). Nevermind Medicare for all: most people would be better off if they were allowed to buy into Medicaid. That’s how bad Obamacare has become.

The worst part of all of this is that the vast majority of the decrease in the uninsured population has been through the expansion of medicaid rolls. We could have had a much simpler and less expensive system if we simply expanded medicaid further and left the private market alone. Indeed, that was what we did in the 90s, when SCHIP (State’s Children’s Health Insurance Program) was started to increase coverage for children. It is widely considered a success (if anything, most people argue it should be expanded further) and didn’t mess with the private market.

I’ve been wanting to start a small business for some time now,..but considering ALL the hoops one has to jump through to get started, let alone the extra tax liabilities, I just don’t think it’s worth the effort !! I’ll consider things AFTER the election to groak whether it seems in my interest to do so…………….

but you know, for Jamie, Lloyd, and the rest…it’s gravy..every fucking day !

CurlyDan – Yes, insurance is the I in FIRE economy. Lot of stock buybacks and M/A in other words, consolidation. Final stages of the big getting bigger.

My answer as a small business owner was to become a micro business, learn certain coding skills, though I have IT management and business skills and do it all myself. If I need a hand beyond my skills I know enough people that will take on small programming job. Since my primary business is IT Healthcare, I have had some trickle down from the surge in the I of FIRE economy but it isn’t worth writing home about and I am terribly exposed to the economy. So people like me not hiring is certainly not helping the economy.

Plus the big corps (that didnt get am exemption, err buy government) hiring only part time workers. From that angle Obamacare tax is a total disaster, plans costs drain a ton of money from discretionary income.

I have been shrewd enough to store wealth slowly in certain assets and my property is not even in my own name. I can be mobile, work out of a room if had to and rapidly increase wealth. At 45 in decent health, get some exercise, supplements and moderate of habits. But if I had a major medical emergency I would go to the ER. I would laugh at a $100k bill and never pay it. I would bankrupt myself like I did when RBS refused to extend the term of my LOC in 2011.

Instead of getting paid $200k they got nothing, my lawyer who was sexy and sat right on top of the BK reviewers desk with her tits in his face got $2k. The underwriters Citizens collected old PC’s that were worthless as collateral. They coul have got better but they were disgusted with RBS. RBS wanted the bailout.

My wealth is also stored with having made some investor connections. Have an IT marketing opp they like and I will have the capital in a few months. No big hurry on it though. These.dont care about my credit.

I write everything off except entertainment, I do follow the law and pay taxes.This year paying the Obamacare tax. Next year since on paper my income is just above poverty line I will get an Obie plan for $300 a month and consider it catastrophic coverage. The only reason I will do that is because I do have some modicum of social responsibility. But this political fascist environment is making that a struggle of consciense when attempting to be forthright, have to spend far more time forced to play games.

For a time, I did take those loan repayment savings and distributed some.really good health information, stuff like how digestive health effects chemical balance and how to avoid, minimize
a shrink. So it isnt that I dont want to give more back as mentors trained me, it is that corrupt political operators have driven the economy in such a ditch I cant do more philanthropy. I will say I see a lot of wealthy people talk the talk about making a better world but ask them for a check and most will just say to network to raise funds like they did 40 years ago as if the two economies then and now are the same. Entrepenuarship is at a 40 year low.

To get funding who you know always mattered, now it is critical or tough shit. Investors want an early stage company to buy or fund. By the time one can if possible build one with bootsrapping one doesnt need them.

The ‘pound of flesh’ is now five pounds. I have seen a few companies begin positioning for innovation but they like me see this as a couple years down the road to begin planting a hand full of seeds.

Since things are cyclical, make your grandkids a video and stick it in a vault for 40-50 years for when the financial parasites come back and premptive strikes. Thank you for your time in allowing me to share my experiences and opinion. Luckily, we still have that going for us in America.

Thank you, Quantum Future. Seems like the only people who can raise any funds these days are Under 30, Stanford/Ivy League types with MBAs or Comp Sci degrees in hand. Good health and good wishes to you!

I don’t think I’ve ever heard made what seems to me to be a staggeringly obvious argument. What business do insurance companies have meddling with healthcare? I’ve seen claims that the overhead costs for Medicare are 3% and for private insurers are 30%. Wouldn’t we reduce medical costs in the US to a level similar to those of comparable countries if we got the insurance companies out of the mix? Are they really that powerful?

I am fortunate, I guess, to be old enough for Medicare and have a Medigap policy that costs us nothing through my wife’s employment by the state of California. Since we retired, we have not paid out a penny in medical costs other than for vision and dental. I’ve had a couple of serious conditions, but no hospital stays. If that is possible for us, surely it is possible for all. Obamacare, I have sadly concluded, is a fraud. Medicare for all and widely available and genuine competitiveness and fairness that are mercilessly enforced are the only answer. Senator Sanders is the only presidential candidate on the current scene whose platform comes close to that.

Reading the post and the comments, all I can do is reiterate the obvious: health insurance is not health care.

The anecdotes mirror experiences among my own family members, and it’s infuriating. The obscene amounts of money being paid to insurance companies for little return are preventing people from saving for retirement, forcing mothers back to work when their babies are only months old, preventing saving for college. It is keeping money out of the local economies.

It’s been great for industry executives and lobbyists, but I don’t believe the people allegedly being “helped” by the current system are any healthier for it, physically, mentally or financially.

The crapification of health care financing started a decade or more before Obamacare. Otherwise Hillarycare would not have been on the political agenda at all in 1992. Obamacare has failed to deal with crapification as a matter of political policy from within the office of the Chair of the Senate Finance Committee not to deal meaningfully with the continuing and accelerating crapification.

At the moment, there are really three policy choices: treat health care as infrastructure and fund it with taxes; treat health care as a private business and fund it with savings schemes; treat health care as a private business and fund it with risk pooling schemes. Only the last option can be called “insurance” to any meaningful extent.

What we know about unregulated saving schemes and risk pooling schemes is that that large pool of prepaid cash sitting waiting for expenses to pay is too strong a temptation for most managers. Saving scheme fraud and risk pooling fraud in unregulated environments tends to be epidemic and leads to frequent bankruptcies of those schemes.

Those tendencies seem to carry over to attempts to create private-public hybrid schemes.

Providers seem to have difficulty understanding that most of their patients can no longer afford to support them in the style to which they want to become accustomed. Most medical schools are even further into that same fantasy world. Financial medical school education with individual student loans has to be the looniest scheme for trying to maintain public health.

Most people understand this at an intuitive level. That’s why they freak out when an epidemic or pandemic appears on the horizon. Overwhelming the US fee-for-service system only takes a matter of enforcing the stated billing charges by providers under epidemic or pandemic conditions. If you say that that will never happen, you are saying that at base even the US health care system requires substantial amounts of socialism. And that the private sector self-rationing that goes on by people who don’t get treatment they can’t pay for likely would not be tolerated if those who could afford to pay for treatment were at risk for the conditions those people left out were leaving untreated.

The American people have clearly the health care system they voted for. Too bad they were not given fully informed consent before voting. Too bad the BS continues to avoid the real social issues in healthcare in a wave of me….me…me…me…me. Putting the full weight of pre-existing conditions on individual insurance customers is a corporate political gambit that seems to be working. Too bad those companies might spook the voters to repeal Obamacare altogether, including the repealing prohibitions on the abuses that drove the legislation in the first place.

It started with Nixon and encouraging HMOs probably, so yea it started decades before Obamacare and decades before Hillary.

I always think if there was a pandemic, wouldn’t the large number of homeless people living and sleeping in the streets be at least as much of a problem as anything else, although no they probably don’t have health insurance either.

I love the way the “subsidy” on insurance takes the form of an advance tax credit based upon one’s estimated future income so that people have the chance to get a nasty surprise at the end of the year AND so the system can be more complicated. Could they have come up with a more idiotic way of doing it?

I am disappointed in “my fellow USians”, that Sanders isn’t doing better in the D primary relative to H Clinton. USians correctly complain about the barbaric ACA, & the pre-ACA situation, but are not sufficiently supporting Sanders, the only candidate proposing a civilized Canada-esque MedicareForAll system.

In the meanwhile, I feel like at least it is worth pursuing health-related areas within personal control: nutrition aka eating vegetables, & exercise. Stress management is a 3rd pro-health aspect, but minimizing stress is difficult in Barbaric Murica, & the ACA itself is often a source of stress that in some cases may even degrade health as much as whatever health service is actually obtained improves health.

It would be interesting to know the amounts of money were taxed via the ACA Individual Mandate vs. the ACA Employer Mandate, for a given tax year. I wouldn’t be suprised if Individual is 10X+ the amount as the Employer.

In the later mid-aughts at my old, smallish company (around 80 employees) we were hit with a ton of bad luck, health-wise. A child of a co-worker was diagnosed with a late-stage cancer that tends to hit kids in adolescence. Two other collegues who worked desk jobs ended up on long-term disability for almost a year each due to chronic conditions, and another coworker spent months in and out of rehabilitation programs. The upshot was that our out-of-pocket premium as employees went to $5000/year, which if I remember correctly was 1/3 the total (employer paid the other 2/3), and by the time I left the deductible was $7000/year. Then the recession hit, and, rather than lay anyone off, management decided to cut everyone’s pay by 20% (which I agree was better than the alternative). I left because I couldn’t afford to work there anymore; we couldn’t make rent and buy groceries and keep that job (both companies my husband worked for in that time period went under).

The good news is that the kid with cancer survived and is walking, something the family was told would take a miracle. Kid also can no longer be refused coverage on the basis of being a cancer survivor, which is also very good. The bad news is that apparently that the level of premium and deductible that I considered a response to the mini-disaster that had developed at myour old job appears to be the norm for “affordable” individual health care coverage now. That fact alone has made me sympathetic to the ridiculous number of attempts the Republicans have made to overturn the ACA.

I feel trivial posting about problems just getting coverage while others are having serious health issues, but an update:
Went online to try to fix mess. Failed, unless I wanted a hearing somewhere. WTF? NO. Tried calling the # the people online gave us. Got a real person, who told me this was the wrong # and they would transfer me to the right person. They transferred me. To a computer menu with no options that fit our situation, and no option to speak directly to a representative. I tried hitting 0 # * & other things at random to see if it would give me a real person, but no. So I called the # on the anthem blue shield card telling me to check out my (apparently disappeared) coverage online. Obviously, the online route didn’t work, so let’s try phoning them. Got a recording, then put on hold. I waited on hold ONE HOUR. 1 hour. I hung up. Our coverage was supposed to start March 1. We were, I believe, supposed to have paid for it before then. I have no idea what is going on. Neither of us particularly have any desire to deal with this further. Speaking for myself, I have a LOT of other things I’d rather do with my time, and a lot of more important things to do with my time. If they try to penalize us for not joining even tho we signed up in timely fashion or not paying even tho no way we could pay I’m going to seriously go off on someone. I realize it won’t be the fault of whoever gets stuck talking to me when this finally comes up again, and I’m going to try to remember that when I call again if I call again, but if they aren’t very very nice & conciliatory & ideally problem solving, I’m going to give someone one hell of an earful (esp if I get stuck on hold again, even if for a lot less than an hour).

Too much of the conversation is focused on the costs, in terms of dollars. Too little discussion addresses the phenomenal loss of personal time spent, often at times of emotional crisis, just trying to understand this God-awful system of ours.

Talk about the human toll, the stress, the fear, the anger, the debt, the bankruptcies. Talk about the byzantine and unfathomable rules and procedures put in place with absolutely no concern for the herculean effort people must expend just trying to figure them out.

Talk about how the system is completely prioritized around profit, not wellness and recovery for the patient and their families, or the time wasted, and then talk about the fact that the “system” is, in fact, a bunch of rich white men scheming on how they can make themselves richer.

The American health care system stands alone for its cruelty and inhumanity. Try putting a cost on that and all of the time in our lives we will be forced to spend dealing with this utter bullshit.

Lots of anecdotes here. How about another?
My significant other and I are on Medicare and also a Medicare “advantage” plan (mainly to get 1. drug coverage and 2. to get an annual out-of-pocket cap).
We have not had the least problem or complaint about the plans, the coverage, the pricing, the billing or the communication, not with any doctor ever not providing care.
I do have problems with the organization, administration and billing practices of health-care providers. I put the blame for systemic problems on them, where I think it properly belongs. They buy excess expensive equipment, build expensive facilities, employ armies of needless staff doing make-work paperwork, pay excessively for doctors and too cheaply for techs and are very inefficiently administered, with bureaucratic labyrinths pretending to be customer service.

Last and least. As a retired general pediatrician, who worked for Northern California Kaiser-Pemanente
after my Army stint, I can unequivocally opine that all for-profit private health insurance is a malignant
scam, and it’s stupid and self-serving to protect it. I was stationed in Germany, and care there is excellent
and inexpensive. They laugh at us.

You guys have covered this exhaustively, so I’ll just offer some mundane, godawful stupids this fraudulent system imposes on even the most basic service transactions. My Obamacare experience has been a clusterfuck of income changes and statements and deductibles, but let’s consider what happens if you try to use this crap.

CVS started sending me back-billing for prescriptions received 3 months earlier. The bills were $200, but they were wrong. I attempted to communicate with them by phone, email, webform and certified mail to resolve an issue in which they clearly were wrong. They cancelled my prescription privileges. They ignored everything and put me in collections. It was only after the intervention of the state department of insurance that CVS finally sent a letter admitting fault and withdrew the collection attempts.

Believe me, six months of this is a huge tax on your time.
Many people would have paid simply to get on with their lives.

I requested a referral to an ENT Otolaryngologist and 24-hour cardiac halter. The clinic tells me a “referral specialist” will mail me 2 referrals, and verify for in-network insurance coverage. They said this. When I get it and call the nearby hospital appointments person, she tells me the referral doesn’t name a specialist and they cannot accept a referral that simply says “ENT clinic.” OK. So she schedules the diagnostic halter. She takes my insurance information. Before I hang up, it occurs to me to ask her to check if this is in my insurance network. She says, “oh, you’re not in network for anything at this hospital, and you would have to pay out of pocket.”

She never bothered to check in the first place. It’s not the procedure.

I have many more like this.

The time I got a “referral” from an allergist for a sinus CT scan at the same hospital complex she practiced in. I walked across the street, presented my “referral” and my insurance card. they photocopied it and handed it back. But didn’t actually do anything with it. I did the scan, which was unremarkable. Six months later I get a bill for $3,200. I call them and ask them WTF? They tell me it wasn’t a referral, it was a “work order.”

I spend a year writing certified letters and asking multiple doctors to write me a “reverse referral” which they all refuse, saying they will be penalized $800 for rectifying their own incompetence.

Finally I write a letter cursing ten generations of insurance professionals to health care hell and the ship they rode in on.

I never heard from them again.

The entire goddamn thing is designed from the ground up to screw people. Most of my energy is directed at never getting sick enough to need much “health care.”

Well, I hope this puts to rest all the right-wing drivel about Obamacare being socialist. It is rapacious, fascist capitalism at its finest.

I would like to see Cruz or Rubio win the presidency along with a Republican House and Senate. They will start to mouth off about getting rid of “communist” Obamacare. Then they will get visits, checks, and bags of cash from Big Pharma and Big Med. So instead, they will tweak it (make it worse for the insured), declare a major victory, rename it CapitalCare, and go back to getting blowjobs from their male pages while sipping imported liquor and doing lines of coke (provided courtesy of the Mexican cartels).

You really wanna make a change? Try a few neutron bombs on DC and Wall Street. (Oh, for fuck’s sake, DHS, I was speaking metaphorically…yes, it’s a big word. Try a dictionary. How do you spell “dictionary”? Um, dick…never mind.

Here is my personal Obamacare horror story. I have been working for a small 12-employee company for 8 years now. When Obamacare was introduced, boss decided she was done with the paperwork of managing our employer health insurance and would dump us all on the individual market to fend for ourselves. After vigorous protestations we agreed on a compromise that she would instead enroll the company into the NYS exchange and we would use the exchange as employees rather than individuals, and the company would assist with $300/mo for premia.

From having a relatively decent, relatively cheap (low monthly premia, low deductible, reasonable copay) plan before Obamacare, we were thrown in a situation where (since we made too much for any subsidies) the only plans we could reasonably afford were Bronze plans that covered basically nothing up to $6K or so. Being in fairly good health, I didn’t let this bother me at the time.

Fast forward several years and my wife becomes pregnant with our first child. I upped our employee insurance to Gold, figuring eating into our savings for one year would make more sense than gambling that the pregnancy would be completely complication-free, which was the only scenario where staying on Bronze would make sense. Baby was due mid-January. Wife quit her job.

One month after we switched to the Gold plan on Health Republic, the Republicans killed the coops and our plan was terminated the month after. Mind you, we were first told (in mid-October) that HR would be terminating our insurance on 31 December, so we would just be able to use open enrollment to re-enroll; two weeks later, we received notice that HR was actually shutting down on 30 November, and if we wanted to be covered for December we better get on it because enrolling in a new plan after the 15th of October would mean we would not be covered that month.

Thus began our “shopping” which Obamacare so prides itself on. It was a full week, 9-5, while at work, of online research, calling the exchange, calling insurance companies, and calling and visiting my wife’s OBGYN to make sure that we could get onto a plan that they actually accepted. We learned some fun things:
1. The OB did not accept any of the plans offered through employer. Apparently, good OBs don’t take sh!t plans like Metroplus. Who knew?
2. Of the two dozen or so other OBs my wife called to see if she could switch OBs, the only ones that would take her as a patient that far advanced into pregnancy were those who did not accept any insurance. NONE of the in-network OBs for ANY plan accepted pregnant patients past 12 weeks. Again–who knew?
3. The only insurer that my wife’s OB accepted and that also offered individual plans did not, for whatever reason, offer these plans through the employee exchange. It was also insanely expensive, but this being our only choice, we just bit the bullet. Since we couldn’t purchase it from the exchange, we ended up just downloading the application from the insurance company website and sending them a check.
4. The cherry on top of this trainwreck was that our new insurer was changing their network after December 31, AND my wife’s OB was changing their network at the same time. So, we really didn’t know until after we’d signed up for the new insurance whether the delivery would actually be covered in mid-January! (Admittedly, this is probably not Obamacare’s fault, but it added some extra fun to the proceedings.)

In sum: Obamacare killed our good insurance, then underinsured us, then killed our coverage again when my wife was six months pregnant, then forced us to waste about 80 man-hours “shopping” during business hours, then essentially strong-armed us into paying a full year of ridiculously high premiums for a procedure occurring in the second month of coverage.

Aside from the pre-existing condition thing (pregnancy), which I can agree is a good thing about it, Obamacare really tried its best to screw us from day 1. It’s an absolute embarrassment: my parents, who are doctors in Ecuador, can’t believe the money we are haemorrhaging to pay for the delivery. In Ecuador, delivery is completely covered at public hospitals, which are (I hear) very good. Ecuador has better health care than The Greatest Country In The History Of The World.

NC, perhaps you can do an informal poll of this question on your site, with people “voting” & optionally explaining in the comments:

“Do you support repealing the 2010 Affordable Care Act”

I struggled answering this question from a question list on projectvotesmart, to help me ascertain which US Senate & House primary candidates’ policy set is closest to my own. I am at a mild “No” on this question, but I could be persuaded otherwise. IIRC as Lambert says, the ACA randomly creates different cohorts of winners & losers.

It would be interesting to read the NC community’s take on this question.